State health agencies and advocates are pleading with the federal government to drastically change a key part of Medicare they say is contributing to the country’s opioid epidemic. A growing number of physicians say a computing factor in the reimbursement program is a dangerous incentive to prescribe potentially dangerous painkillers that are highly addictive. The overprescribing of painkillers is a key contributor to the epidemic that kills more than 72 Americans every single day.

The outspoken physicians and hospital administrators want to remove pain questions from patient satisfaction surveys. The doctors and C-suites argue that these surveys pressure doctors to prescribe unnecessary opioids in hopes of getting a better score on patient surveys. The results of patient surveys are used to determine a hospital’s reimbursement rate.

It is easy to spot the conflict here. Tying money to great reviews can easily lead to undue pressure on doctors to prescribe opioids to make a patient happy in order to get a good score.

The groups have sent a letter to the Joint Commission, a group that accredits hospitals and other healthcare organizations, as well as to the Centers for Medicare and Medicaid Services (CMS), hoping to get those questions removed.

“Aggressive management of pain should not be equated with quality healthcare as it can result in unhelpful and unsafe treatment, the end point of which is often the inappropriate provision of opioids,” the letter from the group said.

So how did this all start?

In the early 2000s, Uncle Sam discovered a new metric to compute patient satisfaction. The federal government then mandated hospitals to begin measuring and reporting satisfaction survey results. Proponents of this metric would argue that the CMS mandate is an attempt to guarantee quality in the healthcare for which Uncle Sam is paying.

The cynical opponents see the patient satisfaction mandate as an indirect way for the federal government to reduce payment. In 2012, CMS began to tie satisfaction survey results to Medicare reimbursement. How big a hunk of dynamite is this metric? Well, nearly a billion dollars in payments to providers that failed to meet the patient satisfaction metrics were at stake in 2013. KA-BOOM!

Almost immediately, vultures and hawks swarmed the sure-fire administrative panic. Survey companies like Press-Ganey, Picker, and Gallup were hired to begin mailing and collecting surveys.  Hospitals hired consultants to instruct their employees in hospitality and customer service. Doctors and nurses memorized scripts as if presenting a one-act play to their patients.

But the biggest area affected by patient satisfaction surveys has been the emergency room setting. Several studies suggest that ER doctors have drastically changed their practice in order to avoid negative patient satisfaction reports. Prescribing painkillers, even when not entirely necessary, was needed to get paid by Uncle Sam.

Two surveys of more than 800 emergency physicians by Emergency Physicians Monthly and the South Carolina Medical Association reported that more than 50 percent of the ER docs routinely ordered tests and procedures, prescribed medications, and even admitted patients to the hospital unnecessarily.

Why? Because patient satisfaction affects their bottom line.

According to USA Today, the management consulting firm Hay Group found two-thirds of physician pay incentives are based on patient satisfaction scores. The issue at the heart of the matter is that American healthcare consumers believe more care equals better care. So the U.S. physicians have fed into that consumerism belief as a matter of fiscal self-preservation.

Tying reimbursement rates to patient satisfaction surveys is part of a larger effort by the federal government to shift toward reimbursements tied to quality of care, rather than the traditional fee-for-service model, a 2012 New England Journal of Medicine article noted.

As part of an Affordable Care Act initiative meant to reward quality care, CMS is allocating some $1.5 billion in Medicare payments to hospitals based on criteria that include patient satisfaction surveys. The survey questions that raise physician eyebrows include: “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” And: “How often was your pain well controlled?”

Doctors and legislators are now struggling to contain the nation’s opioid crisis. “The government is telling us we need to make sure a patient’s pain is under control,” Dr. Nick Sawyer, a health-­policy fellow at the UC Davis department of emergency medicine, said to USA Today. “It’s hard to make them happy without a narcotic. This policy is leading to ongoing opioid abuse.”

How bad has the crisis become?

Since 1999, fatal prescription-­opioid overdoses in the U.S. have quadrupled. According to the Centers for Disease Control, more than 47,000 Americans died of a drug overdose in 2014, a record high. The smoking gun is that more than 60 percent of those deaths involved an opioid. Already taxed U.S. emergency rooms treat more than 1,000 people every day for misusing prescription opioids.

Patient-satisfaction surveys are not the sole reason for this crisis. But there is no dispute the surveys are the equivalent of throwing gas on a fire. A 2012 study in the Archives of Internal Medicine found that the most satisfied patients are more likely to spend more on prescription drugs and have higher mortality rates. In a 2014 survey published in Patient Preference and Adherence, found that more than 48 percent of physicians reported prescribing inappropriate narcotic pain medication because of patient-­satisfaction questions.

Compounding the problem are savvy patients aware of how the system now works. One physician wrote that drug seekers “are well aware of the patient satisfaction scores and how they can use these threats and complaints to obtain narcotics.”

CMS disputes a correlation between its surveys, a hospital’s reimbursement money, and opioid abuse. In March of this year, CMS physicians wrote in JAMA that the patient satisfaction survey accounted for 30 percent of a hospital’s total performance score in fiscal year 2015, with pain management one of eight equally weighted dimensions, along with factors like nurse communication and cleanliness and quietness, USA Today reported.

The lesson learned may be that surveys are helpful mirrors for providers to implement necessary changes to the delivery of healthcare, but dangerous if a patient’s happiness is connected to compensation.